Citation Nr: 0814233 Decision Date: 04/30/08 Archive Date: 05/08/08 DOCKET NO. 06-26 476 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUE Entitlement to service connection for post-traumatic stress syndrome (PTSD). REPRESENTATION Veteran represented by: Military Order of the Purple Heart of the U.S.A. ATTORNEY FOR THE BOARD K. K. Buckley, Associate Counsel INTRODUCTION The veteran served on active duty in the United States Air Force from September 1963 to October 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a December 2005 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma which denied the veteran's claim of entitlement to service connection for PTSD. The appeal is REMANDED to the RO via the VA Appeals Management Center (AMC) in Washington, DC. VA will notify the veteran if further action is required on his part. REMAND The veteran is seeking entitlement to service connection for PTSD. After having carefully considered the matter, and for reasons expressed immediately below, the Board finds that this case must be remanded for further evidentiary development. Reasons for remand Additional medical evidence In order for service connection to be awarded for PTSD, three elements must be present: (1) a current medical diagnosis of PTSD; (2) credible supporting evidence that a claimed in- service stressor actually occurred; and (3) medical evidence of a causal nexus between the current PTSD symptomatology and the claimed in-service stressor. See 38 C.F.R. § 3.304(f) (2007); see also Cohen v. Brown, 10 Vet. App. 128 (1997). With respect to element (1), a current medical diagnosis of PTSD, the veteran has submitted private treatment records from Dr. L.C., Psy.D, dated September 2005. In the September 2005 report, Dr. L.C. neither mentioned nor diagnosed PTSD; rather she diagnosed the veteran with Major Depressive Disorder. Review of the file indicates that the veteran was diagnosed with depression in 1999, for which he is prescribed Paxil and Amitriptyline. Medical records pertaining to the diagnosis and treatment of the veteran's depression are absent from the file. The veteran should be contacted and asked to identify any medical evidence pertaining to his psychiatric disability. It appears that the only competent medical evidence now of record which includes a diagnosis of PTSD is a July 2006 letter from Dr. W.R., M.D. In the July 2006 letter, although Dr. W.R stated that "[a]ll of these symptoms are related to [the veteran's] experiences in Vietnam...," he made no findings regarding the veteran's exposure to a traumatic event. See American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; see also 38 C.F.R. § 4.125 (2007). The Board further notes that the veteran has not referred to any specific stressor other than his learning, while he was stationed in the continental United States, of the death in Southeast Asia of a service member he knew. In short, there is now of record conflicting and inadequately explained medical evidence as to whether or not PTSD exists and if so what is its cause. These medical questions cannot be answered by the Board. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) [the Board is prohibited from exercising its own independent judgment to resolve medical questions]. The questions include whether the claimed PTSD in fact exists and, if so, the relationship, if any, between such and the veteran's active service from September 1963 to October 1967. These issues must be addressed by an appropriately qualified physician. See Charles v. Principi, 16 Vet. App. 370 (2002); see also 38 C.F.R. § 3.159(c)(4) (2007) [a medical examination or opinion is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim]. SSA records The evidence of record indicates that the veteran receives Social Security Administration (SSA) disability benefits. Medical records associated with any such decision may shed light on the nature and origin of the veteran's claimed disability. An effort should therefore be made to obtain such records. See Murincsak v. Derwinski, 2 Vet. App. 363 (1992) [VA's duty to assist includes obtaining records from SSA and giving appropriate consideration and weight in determining whether to award or deny VA disability compensation benefits]. Accordingly, the case is REMANDED to the Veterans Benefits Administration (VBA) for the following action: 1. VBA should contact SSA for the purpose of obtaining any records from that agency that pertain to the veteran's claim for disability benefits. Any records so obtained should be associated with the veteran's VA claims folder. Any notice from SSA that these records are not available should be noted in the veteran's claims folder. 2. VBA should contact the veteran and request that he identify any relevant recent medical examination and treatment records pertaining to his psychiatric disability. VBA should take appropriate steps to secure any medical treatment records so identified and associate them with the veteran's VA claims folder. 3. After the above-indicated records have been associated with the veteran's VA claims folder, VBA should make arrangements for the veteran to be examined by an appropriate specialist for the purpose of addressing the existence of PTSD. The veteran's VA claims folder, including a copy of this REMAND, must be made available to the examiner. Any diagnostic testing deemed to be necessary by the examiner should be accomplished. The examiner should either diagnose PTSD or rule it out as a diagnosis. If PTSD is diagnosed, the examiner should specifically comment on whether the veteran's stressor, learning of the death of a fellow service member, constitutes sufficient trauma to initiate PTSD. The report of the examination should be associated with the veteran's VA claims folder. 4. After undertaking any additional development which it deems to be necessary, VBA should then readjudicate the veteran's claim. If the benefit sought on appeal remains denied, the veteran and his representative should be provided a supplemental statement of the case and given an appropriate opportunity to respond. Thereafter, the case should be returned to the Board for further consideration, if otherwise in order. The veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2007). _________________________________________________ Barry F. Bohan Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2007).